NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
Extract:
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Question 2 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits
Extract:
Question 3 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
Question 4 of 5
The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.'
Correct Answer: A
Rationale: Assessment is required to determine the cause of the client’s symptoms, as they could indicate complications such as vessel closure, bleeding, hypotension, or dysrhythmias. Talking with the client to assess current symptoms is the most immediate and appropriate action. Encouraging eating, ordering medication, or reviewing past vital signs does not address the need for current assessment.
Question 5 of 5
Which action is most likely to ensure the safety of the nurse while making a home visit?
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.